ITE Review Must Know Cardio Angela Pugliese MD Department of Emergency Medicine Henry Ford Hospital Outline Dysrhythmias ACS CHF/Cardiogenic Pulmonary Edema Cardiomyopathies DVT PE Pericardial Disorders Myocarditis/Pericarditis Aortic Dissection/AAA HTN Emergency/Urgency Valvular Heart Disease EKG Trivia First and Foremost KNOW ACLS Meds that can be given through the ET tube - LEAN L - lidocaine E - epinephrine A atropine N nalaxone Give 2 times normal dose diluted in normal saline Dysrhythmias Always assess hemodynamics. SHOCK THE UNSTABLE PATIENT Dysrhythmias SVT Regular Vagal maneuvers and adenosine Afib Irregularly irregular Normal EF CA/Beta blockers, Low EF dig/amiodarone Think anticoagulation WPW Short PR, delta wave Narrow tx like SVT Wide procainamide vs amiodarone A-flutter Rate control MAT Irregularly irregular, p-wave variation 3 types Treat underlying cause ie COPD/CHF Avoid beta blockers, think CA block or mag Dysrhythmias Sick Sinus Syndrome Combination brady-tachy arrhythmia Refer to cardiology for pacer Vtach 3 + PVCs with rate >120 Amiodarone, lidocaine, procainamide Torsades Axis swinging from + to in single lead Mag and overdrive pacing Vfib ACLS Dysrhythmias AV Blocks 1 st prolonged PR, no treatment if no symptoms 3 rd AV dissociation, requires pacing 2 nd Mobitz 1 (Wenckebach) Mobitz 2 avoid atropine, needs pacing ACS Continuum Angina Unstable Angina NSTEMI - STEMI AMI STEMI or CP with elevated markers Treatment ASA, plavix, heparin, nitro Thrombolytics TPA Give within 30 minutes if PCA > 60 min away Complications Vfib highest in first hour LV failure >20 % loss = pulm edema > 40% loss = shock CHF/Cardiogenic Pulm Edema Left sided Ischemic heart disease, HTN Aortic/mitral valvular disease Right sided Left sided failure, pulm HTN, tricuspid/pulmonic disease Signs and symptoms SOB, cardiac asthma Pleural effusions S3, JVD, dependent edema CHF/Cardiogenic Pulm Edema CXR/Symptom progression Stage 1 cephalization, dyspnea Stage 2 interstitial edema (kerley B lines), dry cough Stage 3 alveolar edema (butterfly pattern), wet cough pink frothy sputum Lab BNP 3cm difference) Diagnosis Duplex US (repeat testing in 7 days) Tx Aimed at preventing PE Anti-coagulation Thrombolytics (vascular surgery consult Cerulea Dolens Alba Dolens Pulmonary Embolism Presentation Dyspnea Classic triad dyspnea, pleuritic CP or tachypnea CXR Dyspnea, hypoxia and normal are very suggestive Diagnostics EKG, d-dimer, V/Q, CT, Angiography Tx Anticoagulation Thrombolytics Hemodynamic instability TPA, 100 mg over 2 hours PE CXR Findings PE - Diagnostics EKG sinus tach most common S1, Q3, T3 D-dimer know Wells, low risk pt only V/Q Limited in lung disease Needs clinical context Low-mod pretest prob with normal study 98% exculsion CTA 95% sensitive for segmental or large PE, 75% for subsegmental Angiography Gold standard Pericardial Disorders Pericarditis Idiopathic and viral most common causes Diagnosis Hx sharp precordial pain relieved by sitting up and leaning forward PE friction rub EKG diffuse concave ST elevation, PR depression Echo to look for effusion BUN/Crt look for uremia Treatment Outpatient NSAID for idiopathic/viral and reliable pts Pericardial Disorders Pericardial Tamponade Becks Triad hypotension, JVD, muffled heart tones Tachycardia is earliest finding Diagnosis EKG electrical alternans, low voltage Echo gold standard, large effusion, diastolic RV collapse Treatment Monitor, IV, O2 Aggressive volume resuscitation and pressors if needed Cardio/CT surgery consult and pericardiocentesis (under US) Myocarditis Presentation Range from non specific fatigue to florid CHF Watch for tachycardia out of proportion to fever Diagnosis Echo dilated chambers with diffuse or focal hypokinesis Labs elevated ESR, trop rise and fall slowly Biopsy for definitive Etiology Viral most common cause Treatment Supportive, treat like CHF Avoid immunosuppressives and NSAIDs IVIG for Kawasaki Endocarditis Localized infection of endocardium with hallmark vegetation Causative Organisms Native valve non-viridan strep Prosthetic valve coag-neg strep ( 95 % infrarenal Males > 60 Presentation Thing middle age male with syncope or near syncope and lower abdominal or back pain PE classic pulsatile abdominal mass Diagnosis and Management Bedside echo IV, O2, monitor 10 units of blood on standby Surgical consultation HTN Emergency/Urgency End Organ Damage Arrest and lower BP rapidly, 30% in first hour DBP > 115 Asymptomatic pt discharge to follow up with PCP Oral agents to lower BP over hours Valvular Disorders Mitral Valve Prolapse Click murmur syndrome High pitched late systolic murmur with mid-systolic click Most common 5-10% of population Presentation Young women palpitations Elderly syncope Treatment Only symptomatic pts Beta blockers for CP or dysrhythmias ASA or anticoagulation with hx TIA/stroke Mitral Regurgitation Acute Rupture chordae tendineae or papillary muscle after Presents with fulminant CHF Apical systolic murmur Tx- hemodynamic support and CT surgery consult Chronic Evolves slowly and usually coexists with mitral stenosis High pitched holosystolic murmur Afib in 75% of patients Abx prophylaxis Aortic Stenosis Etiology 65 calcification Symptoms Exertional dyspnea or syncope Harsh crescendo-decrescendo murmur radiating to carotids Treatment Mild d/c home avoid strenuous activity CHF admit, reduce preload/afterload Refer all symptomatic patients for surgical therapy EKG Trivia EKG & Electrolytes, etc. Hypothermia = J wave or osborn wave Sinus brady an afib w/out RVR Hypokalemia = Prolonged QT Also seen in hypomag Hyperkalemia = Peaked Ts ( ) Prolonged PR, flattened ps, wide QRS (6.5-8) Sine wave, vfib, asystole (>8) Hypocalcemia = Prolonged QT EKG & Electrolytes, etc Hypercalcemia = shortened ST and QT intervals Narrow QRS Digitalis = Sagging ST, concave up Treatment multiple dose charcoal and FAB The END